It's Not Our Fault

This post by Rob Lamberts, ACP member, originally appeared in Musings of a Distractible Mind in September 2008.

Dear Patients:

I know you get frustrated with our office. We make you come in for visits when you think we should handle things over the phone. We seem more focused on your chart sometimes than on you. Sometimes you may even wonder if money has become more important than patients.

To this, I say: I'm sorry. It's not our fault.

We are part of an insane system that requires us to do things in a way that makes life harder for us both. We would love to practice medicine differently, but we simply can't. Here are some examples:

1. Making you come in all the time

I would love to handle your simple problems on the phone or via e-mail. The problem is that if I do this, I am giving free care for which I am liable. People are being sued for nearly everything. If we give you a medicine without seeing you, we are actually more at risk than if you come in. Plus, the only way we can get paid is to bring you in. Insurance won't pay me for handling your problem any other way. Even if we both agreed, we couldn't have you pay for a phone call or e-mail, because we would be breaking our contract with our insurance company.

2. Not ever giving discounts

If I choose to give you a break and not charge you for a visit, I am being nice. Right? Well, according to our government, I am actually committing fraud. That's right, fraud. You see, I can't offer anyone a discount that I don't offer to Medicare patients; and not charging you would mean I have to not charge my Medicare patients. Ridiculous, isn't it?

3. Getting lost in notes

Why do we spend so much time taking notes and not talking to you? Is it so that we can do better medicine? No, we actually think that all this charting is stupid too. The problem is that we don't get paid to see you, we get paid to chart about you. We are paid based on a complex set of rules of documentation and if we are able to document more, we are paid more. If we cut corners so we can spend time with you, we are again viewed as committing fraud.

4. Obsessing about money

When you get your bill from us, you may wonder what all those charges are. And why are we forcing everyone to pay up front and sending people to collections? The problem is, while health care insurance premiums have gone up and inflation has raised everyone's cost of living, our reimbursement has dropped. We get paid less and less for taking care of you, so we have to become much stricter in how we run our business. The practice of medicine has turned into the business of medicine. We didn't do that, nor do we like it. But we have to stay in business, so we do what we must.

5. Not seeing you in the hospital

It seems like the time you most need your primary care doctor is when you are in the hospital, yet we don't see adult patients in the hospital. Believe me, we hate that as much as you do. It is very hard to give your care over to others who see you as "another patient." They don't know your history like we do and are often too busy to answer your questions. We try to communicate with them, but it is just a hard thing to do.

The problem is that we can't afford to see patients in the hospital. The amount of time it takes for the money we get is just not worth it. It came down to what was the least-bad thing to do: stop seeing patients in the hospital, see our families less or see our salaries drop. As primary care providers, we are not paid enough to let our salaries drop, so we chose our families. It was one of the hardest choices we ever made.

6. Acting paranoid

Why does the nurse always tell you to go to the ER when there is even a small chance there may be a problem? Why are you treated like a criminal if you ask for pain medications? The answer? Lawyers. Lawsuits are so rampant in our culture and so it makes us practice "defensive medicine." This means that we can't do what makes sense, we must do what minimizes risk.

And if we are ever thought to be giving pain medications too liberally? We can lose our licenses and even go to jail. It's a dangerous business we are in, but we don't want to do anything to make it more dangerous.

I am truly sorry for the state of things as they are. Perhaps better days are ahead of us. Some politicians are actually talking about paying primary care doctors more. Some people are suggesting that they stop paying just based on charting, but actually reward better work. And some people are even talking about limiting malpractice rewards.

These all sound promising, but remember who it is that is making the decision: It isn't the doctor or the patient, the two people who the whole thing is about; it is the politicians, bureaucrats, and insurance companies controlling this stuff. Unfortunately, with them in charge it is probably not wise to hold our breath.

Stay healthy, and have a great day!

Sincerely,

Dr. Rob

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.
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